EMQs in Clinical Medicine.pdf - Peshawar Medical College

Abdominal pain – answers 167
Helicobacter pylori infection and chronic non-steroidal anti-inflammatory
drug (NSAID) use are important risk factors for duodenal ulceration.
Nearly all duodenal ulcers are Helicobacter pylori positive.
55 Abdominal pain
Answers: B E K H A
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A 21-year-old student presents with a cramping diffuse abdominal
pain associated with alternating constipation and diarrhoea.
Investigations are normal.
Irritable bowel syndrome is associated with a stressful lifestyle. Younger
women (under 40) are more frequently affected. The patient may report
pain relief after defecating/passing flatus.
A 55-year-old smoker presents with severe epigastric pain. The chest
radiograph reveals air under the diaphragm.
Air under the diaphragm can be seen with any perforated viscus.
A 9-year-old girl presents with fever, nausea and right iliac fossa
pain. She says that the pain ‘was around my belly-button before’.
This is a classic presentation of appendicitis, with a central colicky
abdominal pain that shifts to the right iliac fossa once the peritoneum
becomes inflamed. Rebound tenderness can be elicited with appendicitis.
As the appendix may lie in various positions (e.g. retrocaecal, paracaecal,
retrocolic, pelvic), pain may sometimes be elicited by rectal/vaginal
examination. Treatment involves prompt appendicectomy.
A 35-year-old man presents with weight loss, diarrhoea and
abdominal pain. On examination, he has aphthous ulcers in the mouth
and a mass is palpable in the right iliac fossa. Blood tests reveal low
serum vitamin B 12 and folate.
Crohn’s disease is a chronic transmural inflammatory gastrointestinal
disease that can result in skip lesions anywhere from the mouth
(aphthous ulceration) to the anus (e.g. fissuring/fistulae), but favours
the terminal ileum/proximal colon. Small bowel disease can lead to
malabsorption, e.g. iron, vitamin B 12 and folate.
A 45-year-old woman on treatment for TB presents with abdominal
pain and malaise. On examination she is jaundiced.
Pyrazinamide, isoniazid and rifampicin are all recognized causes of
drug-induced hepatitis. Remember that rifampicin is commonly
associated with a transient elevation in hepatic transaminases, but this
does not indicate the development of full-blown hepatitis and so
withdrawal of treatment is not necessarily indicated.